MEDICARE: DIVINE THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1679402184
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE THERAPY LLC

Provider Business Mailing Address
First Line	:	650 PONCE DE LEON AVE NE STE 300
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30308-1864
Country	:	US
Telephone Number	:	470-502-5643
Fax Number	:

Provider Business Practice Location Address
First Line	:	3461 SUMERSBE CT
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-2976
Country	:	US
Telephone Number	:	470-502-5643
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KIARA BALDWIN
Credential	:	LPC, CPCS
Telephone Number	:	770-865-6038

Provider Enumeration Date	:	05/19/2026
Last Update Date	:	05/19/2026

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Directions to “DIVINE THERAPY LLC ” Practice Location

Language	Start Address	Practice Location

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